1. I Am First Name Last Name . the Following Statements Are Based on My Personal Knowledge

DECLARATION

I, [First Name Last Name], being an adult of sound mind and body, hereby declare under penalty of perjury pursuant to 28 U.S.C. § 1746 that the following is true and accurate to the best of my knowledge and belief:

1. I am [First Name Last Name]. The following statements are based on my personal

knowledge.

2. My name is [First Name Last Name] and I currently reside in [City, State].

3. I am a citizen of [Country] and I am the beneficiary of an approved I-140 petition in the

EB-2 category with a priority date of [ex: August 10, 2010].

4. When I learned my priority date would allow me to file an Adjustment of Status

application on October 1, 2015, my attorney and I [or just “I” if no attorney] began

preparing my application [as well as my family members].

5. In reliance on the October 2015 Visa Bulletin, published on September 9, 2015, I spent

money on the following:

a. Medical examination/vaccinations: $[amount]

b. Attorney’s fees: $[amount]

c. Document retrieval: $[amount]

d. Translations: $[amount]

e. Postage and Delivery: $[amount]

f. [Other costs, please list] $[amount] 6. I also suffered hardship as a result of the revocation of the October 2015 Visa Bulletin

because [Add other ways you sacrificed, including time off work, cancelled plans other

financial commitments, etc.].

7. I am very interested in filing my Adjustment of Status application because [provide

narrative explaining what filing the application would mean to you].

I declare under penalty of perjury that the foregoing is true and correct.

Executed this 29th day of September, 2015, by:

______Name of Declarant (Please Print)

______Declarant’s Signature Date